This web page describes how your medical information may be used and disclosed, and how you can get access to this information.
You have specific rights regarding confidential healthcare information.
- You have the right to request restrictions on the use of confidential healthcare information.
- You have the right to request we communicate with you about medical matters in a certain way or at a certain location.
- You have the right to review, inspect and receive a photocopy of your confidential healthcare information. A fee will be charged for copies and mailing.
- You have the right to request changes to your healthcare information, if you feel that information is incorrect or incomplete.
- You have the right to know who has accessed your healthcare information and for what purpose.
- You have the right to a copy of this notice.
- You have the right to decline your or your dependent's participation or withdraw your participation, subject to applicable law.
Your information may be shared with the following:
- renegade.bio, which processes the samples in their Bay Area CLIA-certified lab
- Primary Diagnostics, Inc., which handles registration and scheduling, sample requisition, and returning results to you digitally
- Requisitioning physician
- Applicable government agencies as required by law, such as:
- California Department of Health
- Your residential county department of health
- Those responsible for data safety monitoring related to the project
- Other healthcare professionals for the purpose of providing you with quality healthcare
- For routine health care operations, such as medical records storage or quality review
Your confidential information may not be released without your written authorization for purposes other than stated above. You may revoke your permission to release confidential health care information at any time.
Warning of Risks & Assumption of Risks
Participating in COVID-19 screening involves inherent health risks. There is a risk of exposure to COVID-19 when leaving one's home. There is a risk that upper respiratory tract swabbing may cause discomfort, gag reflex, or nose bleed. All medical procedures have some degree of inherent risk, including unknown risk.
By consenting to participate, I acknowledge that I understand the risk of participating and I voluntarily accept all health risks.
Waiver, Release, and Indemnification
I understand and acknowledge that no person or entity ensures my safety. I know that participating in this screening is a potentially hazardous activity and I hereby assume full and complete responsibility for any injury, illness, or accident which may occur during my participation. I hereby release, waive, hold harmless and covenant not to file suit against the administrators, sponsors, organizers, volunteers, employees, agents or any affiliated individuals or entities associated with this screening from any and all losses, damages, liabilities or other claims and causes of action that may arise out of my participation.
This waiver shall bind a minor participant if agreed to by that minor's parent or legal guardian.
Your consent is required to participate in testing.
I AGREE TO BE TESTED. I UNDERSTAND THIS TESTING SITE WILL NOT FOLLOW-UP WITH MY PRIMARY CARE PHYSICIAN. I UNDERSTAND I WILL BE CONTACTED WITH THE RESULTS OF THIS TEST AND IF IT IS POSITIVE I WILL NEED TO FOLLOW-UP WITH MY PRIMARY CARE PHYSICIAN DIRECTLY. I UNDERSTAND THE PERSON WHO CALLS WITH MY RESULT IS AUTHORIZED ONLY TO COMMUNICATE MY RESULT AND SHARE GUIDANCE PROVIDED BY THE CENTERS FOR DISEASE CONTROL AND PREVENTION AND MY RESIDENTIAL COUNTY DEPARTMENT OF HEALTH. THEY ARE NEITHER RESPONSIBLE OR LIABLE FOR ADDITIONAL FOLLOW-UP OR MY COURSE OF TREATMENT.
Continuous Application of Waiver
This waiver applies to all testing carried out by Renegade Bio for up to 1 year from the date of signature of this waiver unless terminated in writing by me.
Terms of Service
By signing, you agree that you have read and consented to the Terms of Service.
Click and drag your mouse or finger across the box below to sign